<!DOCTYPE html>
<html lang="en">
<head>
    <meta http-equiv="Content-Type" content="text/html; charset=utf-8">
    <meta http-equiv="X-UA-Compatible" content="IE=edge">
    <meta name="viewport" content="width=device-width,initial-scale=1">
    <title>Mednalytics</title>
    <!-- Iconic Fonts -->
    <link href="https://fonts.googleapis.com/icon?family=Material+Icons" rel="stylesheet">
    <link href="../../vendors/iconic-fonts/font-awesome/css/all.min.css" rel="stylesheet">
    <link rel="stylesheet" href="../../vendors/iconic-fonts/flat-icons/flaticon.css">
    <link rel="stylesheet" href="../../vendors/iconic-fonts/cryptocoins/cryptocoins.css">
    <link rel="stylesheet" href="../../vendors/iconic-fonts/cryptocoins/cryptocoins-colors.css">
    <!-- Bootstrap core CSS -->
    <link href="../../assets/css/bootstrap.min.css" rel="stylesheet">
    <!-- jQuery UI -->
    <link href="../../assets/css/jquery-ui.min.css" rel="stylesheet">
    <!-- Page Specific CSS (Slick Slider.css) -->
    <link href="../../assets/css/slick.css" rel="stylesheet">
    <!-- Mednalytics styles -->
    <link href="../../assets/css/style.css" rel="stylesheet">

    <!-- Favicon -->
    <link rel="icon" type="image/png" sizes="32x32" href="../../favicon.ico">
</head>
<body class="ms-body ms-aside-left-open ms-primary-theme ms-has-quickbar">
<!-- Setting Panel -->
<script src="../../assets/reuseCode/top.js"></script>
<!-- Body Content Wrapper -->
<div class="ms-content-wrapper">
    <div class="row">
        <div class="col-md-12">
            <nav aria-label="breadcrumb">
                <ol class="breadcrumb pl-0">
                    <li class="breadcrumb-item"><a href="#"><i class="material-icons">主页</i> 主页</a></li>
                    <li class="breadcrumb-item"><a href="#">支付</a></li>
                    <li class="breadcrumb-item active" aria-current="page">添加付款</li>
                </ol>
            </nav>
        </div>
        <div class="col-xl-12 col-md-12">
            <div class="ms-panel">
                <div class="ms-panel-header ms-panel-custome">
                    <h6>添加付款</h6>
                    <a href="payment-list.html" class="ms-text-primary">支付列表</a>
                </div>
                <div class="ms-panel-body">
                    <form class="needs-validation" novalidate>
                        <div class="form-row">
                            <div class="col-md-6 mb-3">
                                <label for="validationCustom001">患者姓名</label>
                                <div class="input-group">
                                    <input type="text" class="form-control" id="validationCustom001"
                                           placeholder="请输入患者姓名" required>
                                </div>
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="validationCustom002">账号</label>
                                <div class="input-group">
                                    <input type="text" class="form-control" id="validationCustom002"
                                           placeholder="请输入账户号码" required>

                                </div>
                            </div>
                        </div>
                        <div class="form-row">
                            <div class="col-md-6 mb-2">
                                <label for="validationCustom004">付款日期</label>
                                <div class="input-group">
                                    <input type="text" class="form-control" id="validationCustom004" placeholder="付款日期"
                                           required>

                                </div>
                            </div>
                            <div class="col-md-6 mb-2">
                                <label for="validationCustom005">总额</label>
                                <div class="input-group">
                                    <input type="text" class="form-control" id="validationCustom005" placeholder="请输入总额"
                                           required>

                                </div>
                            </div>
                        </div>
                        <div class="form-row">
                            <div class="col-md-6 mb-3">
                                <label for="validationCustom220">支付方式</label>
                                <div class="input-group">
                                    <select class="form-control" id="validationCustom220" required>
                                        <option value="">借记卡</option>
                                        <option value="">信用卡</option>
                                        <option value="">支付宝</option>
                                        <option value="">微信</option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-md-6 mb-3">
                                <label for="validationCustom230">支付状态</label>
                                <div class="input-group">
                                    <select class="form-control" id="validationCustom230" required>
                                        <option value="">已付款</option>
                                        <option value="">未付款</option>
                                    </select>

                                </div>
                            </div>
                        </div>
                        <div class="form-row">
                            <div class="col-md-12 mb-2">
                                <label>详细信息</label>
                                <div class="input-group">
                                    <textarea class="form-control" id="exampleTextarea" rows="3"></textarea>

                                </div>
                            </div>
                        </div>
                        <button class="btn btn-warning mt-4 d-inline w-20" type="submit">重置</button>
                        <button class="btn btn-primary mt-4 d-inline w-20" type="submit">提交</button>
                    </form>
                </div>
            </div>
        </div>
    </div>
</div>
</main>
<!-- Reminder Modal -->
<script src="../../assets/reuseCode/reminderModal.js"></script>
<!-- Notes Modal -->
<script src="../../assets/reuseCode/notesModal.js"></script>

<!-- Modal -->
<script src="../../assets/reuseCode/modal.js"></script>
<!-- SCRIPTS -->
<!-- Global Required Scripts Start -->
<script src="../../assets/js/jquery-3.3.1.min.js"></script>
<script src="../../assets/js/popper.min.js"></script>
<script src="../../assets/js/bootstrap.min.js"></script>
<script src="../../assets/js/perfect-scrollbar.js"></script>
<script src="../../assets/js/jquery-ui.min.js"></script>
<!-- Global Required Scripts End -->
<!-- Page Specific Scripts Start -->
<script src="../../assets/js/slick.min.js"></script>
<script src="../../assets/js/moment.js"></script>
<script src="../../assets/js/jquery.webticker.min.js"></script>
<script src="../../assets/js/Chart.bundle.min.js"></script>
<script src="../../assets/js/Chart.Financial.js"></script>
<!-- Page Specific Scripts Finish -->
<!-- Mednalytics core JavaScript -->
<script src="../../assets/js/framework.js"></script>
<!-- Settings -->
<script src="../../assets/js/settings.js"></script>
</body>
</html>
